gent MAnuAl & underwriting guidelines

P.O. Box 8080 • McKinney, Texas 75070 • www.unitedamerican.com

UAI0300 0511F5754

Agent MAnuAl & underwriting guidelines

General Information 3-4About United American Insurance Company 3How to contact InSphere Insurance SolutionsSM 3Before you begin 3Introduction 3

PASSform Instructions 4Field Underwriting 4-6

Agent’s Responsibility 4Complete an Application 4-5Submit an Application 6Method of Payment 6Effective Dates of Coverage 6Commission Loan Advance 6

Underwriting Department 7-12Selection of Risks 7Underwriting Function 7Underwriting Tools 8Med-Supp Height/Weight Table 8Medical Special Questions 9-10Non-Medical Underwriting Guidelines 11Non-Medical Special Questions 11Medical Underwriting Guide 12

UA Policy and Disclosure Information 13Discount Medical Plan and Application 14Policy Change 15

Type of Change Chart 15Rewrites, Reinstatements, Lapses, Rescissions, Reformations 16

Rewrites 16Reinstatements 16Lapses 16Rescissions 16Reformations 16

TABLE OF CONTENTS

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ABOUT UNITED AMERICANUnited American Insurance Company is the right company for both Agent and policyholders. Ours is a Company built on the solid principles of stability, service, quality and commitment – principles which translate into always doing what’s best for the Agents and policyholders. For over half a century, we have maintained these principles; they have stood the test of time and will continue to guide us into this new millennium and beyond.

For over 30 consecutive years, United American has received an A+ (Superior) rating for overall financial strength from A.M. Best. When you affiliate with United American, you can feel confident you’re with a solid, dependable company that will always be there when you need it. United American has outstanding products, highly dedicated Agents and loyal policyholders. We couldn’t ask for more.

GENERAL INFORMATION

HOW TO CONTACT INSPHERE INSURANCE SOLUTIONSSM

Contact your Field Leader

BEFORE YOU BEGINMake sure you have InSphere Insurance SolutionsSM Agent licensing and Appointment procedures complete. A United American Insurance Company Writing Agent Number will be required on all forms.

INTRODUCTIONOur Agents are an important part of the underwriting process. These guidelines are designed to assist you in understanding both the underwriting process and the action of our Underwriting staff. Attention to these guidelines will help to speed up policy issue and solve placement problems.

Please read this manual in its entirety. It is intended as a guide only. There may be occasions when the Underwriter has additional information based upon the total facts developed during investigation of the case. The decision of the Underwriter is the ultimate determining factor in issuance of coverage.

These guidelines are reviewed periodically by our underwriting staff and medical director. Changes to the guidelines and the underwriting actions may occur without prior notification or reprinting of this guide.

Compliance Sheets are the precise listing of state-specific approved products and required forms used at the time of application. The laws and regulations vary by state and are updated frequently. It is the Agent’s responsibility to use current Compliance Sheets and be knowledgeable of forms related requirements. Current Compliance Sheets are available on the Internet. Always provide the Applicant with a product Outline of Coverage (DS-Form), available from the Supply Department or on the Internet.

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AGENT’S RESPONSIBILITYThe application creates the first impression not only of the Applicant, but also the Agent. The application becomes an important part of your Applicant’s insurance contract. It is critical for the Agent to submit a fully completed, properly signed application along with all the required forms to get the policy issued on a timely basis.

All applications must be negotiated in person. Under no circumstances should applications be taken through the mail, over the Internet, or over the telephone, without prior approval and authorization from the Home Office.

Soliciting an application for coverage can be a rewarding experience for both Agent and the client. Obtaining medical information is paramount to the Underwriting Department in order to make a sound decision. Careful questioning of the Proposed Applicant(s) is important in developing medical histories.

ONLY the Underwriting Department can make a final decision after completion of the underwriting process; therefore never suggest or promise a contract will be issued or issued without change.

The following suggestions will help the Writing Agent get the application completed and submitted properly and help the Proposed Applicant(s) avoid misunderstandings over type and scope of coverage that may be issued.

COMPLETING AN APPLICATION It is necessary that all statements be complete and accurate and that you complete all questions on all Applicants in full. Each circle must be completely filled in. When an incomplete application is submitted, or if any item(s) is missing, it will delay the processing of the application and reflect poorly on the Agent.

1. Suitability - You should determine in each case that any policy sold is suitable to the needs of the Applicant. In doing this, you should consider needs such as a prospective insured’s financial condition, the need for insurance, the values, benefits and costs in relation to any existing coverage that they have, and whether in the totality of each Applicant’s circumstances, this sale is suitable to their needs.

2. The most important step in the underwriting process is accurate and detailed answers to ALL QUESTIONS on the application so that it may be underwritten in an accurate and complete manner. It is the Agent’s responsibility to ask all of the questions in person and record the Applicant’s responses correctly. Failure to properly record complete and accurate information could result in the denial of a claim, rescission of coverage, and/or termination of the Agent’s appointment with United American.

FIELD UNDERWRITINGPASSFORM INSTRUCTIONS

UA PASSFORMUA has implemented a method of entering Applicant data into our computer systems using the Policy Application Scanning System (PASS). PASS enables forms to be scanned so that the required information filled in manually on these forms can be read by machine for automatic electronic transfer of data to our system.

ENTERING APPLICANT DATA

1 Use Blue or Black ink pen – do not use a pencil, graphite pen, erasable ink pen or other colored ink pen.

2 When filling in the fields, print one character per box and stay inside the lines. Align text to the left.

3 It is not necessary to enter periods (.) after abbreviations in the data fields. Example: SR JR APT

4 When there are choices to be made with circles, or bubbles, fill in the area inside the bubble ( Yes ● No ). Do not mark the bubbles with “✗“ or “✓.“

5 Align numeric dollar amounts to the right; never enter a comma in an amount field.

6 Special symbols, such as “#” to represent apartment or suite number, are acceptable.

7 Do not mark over, staple through or cover the corner registration marks or the PASSform ID code.

8 You must use an original form; Photocopies are not acceptable.

M.I.

Proposed Insured'sFirst Name

Last Name

SAMPLE PASSFORM APPLICATION

A recorded interview may benecessary as part of theunderwriting of your application forinsurance. The most convenienttime and place for the interview is:

8 AM - NoonNoon - 6 PM6 PM - 9 PM

Home Phone No.

Work Phone No.

ApplicationVerificationInformation - -

- -

SignedProposed Insured

Amount of InsuranceApplied For

$ ,

Plan Code

APPLICATION FOR INSURANCE * UNITED AMERICAN INSURANCE COMPANYA DELAWARE STOCK CO., WILMINGTON, DE * ADMINISTRATIVE OFFICE: MCKINNEY, TX

11417

3

5

68

4

3. It is essential that the Agent assist the Underwriting Department in obtaining the information necessary to get the policy issued. All medical history should be shown for all individuals listed on the application, including diagnosis, date, and type of treatment, and physician who treated condition or current attending physician. The Writing Agent is not authorized to disregard an Applicant’s answers or to impose his or her own judgment as to what is or is not important to record.

4. Always provide the Applicant with a product Outline of Coverage (DS-Form), available from your Supply Department.

5. Any Agent replacing Health insurance coverage must sign and complete a replacement form if required and send it with the new business application. If replacement forms are incomplete, or not sent with the application, the policy will be pended. Forms may vary by state.

6. Explain the anticipated ratings or riders (Exclusionary or Select Benefit Rider) at the time of application to avoid misunderstanding and possible cancellation of the contract by the insured at the time of delivery. Make it clear to the Applicant that the final decision as to the amount of any rating or the type and scope of any rider that may be attached to the contract is made by the insurance company.

7. The policy specifically defines the exclusions, limitations, provisions and benefits provided under the plan and should be clearly and accurately described to all Applicants. Express the importance of carefully reading the policy. Always remind the Applicant that there is a free look period to give them the opportunity to review the policy in its entirety.

FIELD UNDERWRITING CONTINUED

8. SIGNATURESa. The Proposed Insured must sign the application

in the presence of the Writing Agent. We cannot accept power of attorney, trustee or stamped signatures, or an application for the Applicant signed by the spouse. Applicants age 18 and over must sign their own applications.

b. A parent or legal guardian must sign for all Proposed Insured’s under the age of 18. If a legal guardian signs, tell us what the relationship is to the Applicant and submit a copy of the guardianship papers.

c. We must have the signature of all Applicants over age 18 on the HIPAA authorization form.

d. If Applicant is unable to sign, have them make their mark “X” and have it witnessed by a family member or the Agent. Tell us the reason why they are not able to sign.

9. DEPENDENTS include, in addition to spouse and children, any relative living with and dependent on the Applicant for support. A separate application is required for a non-dependent (EXAMPLE: fiancée). Identify the family member responding to a health question by referring to the number in sequence listed on the application.

Since statutes regarding eligible dependents vary from state to state please refer to the specific policy in question to determine eligibility of dependents subsequent to the issuance of the policy.

10. CHILDa. A natural child of the Applicant, orb. A legally adopted child of the Applicant (including

a child living with the adopting parents during the period of probation); or A stepchild whose primary residence is the Applicant’s household; or

c. A child of the Applicant’s child who is dependent upon the Applicant for more than one-half of his/her support; or

d. A grandchild whose primary residence is in the Applicant’s household, to whom the Applicant is legal guardian or related by blood or marriage, regardless of whether the Applicant treats the grandchild as a dependent for federal income tax purposes.

e. A child for whom the Applicant has received a court order requiring the Applicant to have financial responsibility for providing health insurance for such children.

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FIELD UNDERWRITING CONTINUED

SUBMITTING AN APPLICATIONThe proper submission of new business is a key factor in our ability to provide the best possible service to you and our policyholders. A proper new business submission includes the following:

1. Submit applications timely – One of the most frequent reasons for cancellation is the length of time it takes from the date the application is signed to the date the policy is delivered. UA has very fast policy issue turnaround but it is also important for you to promptly submit your applications and deliver the policies. Applications should be submitted no less frequently than once a week. We do not accept applications that are more than 30 days old when received in the Home Office.

2. New Business Transmittal Form – itemize the premium and fees collected for each new Applicant.

3. Applicant’s check – Postdated checks are not acceptable. We cannot accept an Agent’s check and we cannot accept cash.

METHOD OF PAYMENT:If a policyholder wishes to request a draft date which is different from the effective date of the policy, note it in the top margin of the application if there is not a designated space for it.

1. We do not draft or make policies effective on the 29th, 30th or 31st of any month.

2. If the draft date falls on a weekend or holiday, the premium will be drafted on the next business day.

3. Drafts are combined, and one draft is submitted for the same line of business with the same draft date for the same bank account. Health Drafts, however, are not combined.

4. It is important the insured know when their account will be drafted each month so that adequate funds are available to avoid overdraft charges. Policies with a specific requested draft date may be drafted either before or after the first due date. This depends on the requested draft date as compared to the policy effective date. Generally, a draft date requested within 17 days of the policy effective date will be drafted after the due date (the date the payment must be received by UA). If the requested draft date is 18 or more days after the policy effective date, the premium would be drafted before the first due date. Remember: 17 days or less, Draft After 18 days or more, Draft Before.

5. Direct bill payment mode is available.

6. Company Checks are acceptable for individually or family owned businesses for the Applicants only. Use Sole Proprietor form (SP 9-01).

7. An Agent must never accept cash, money orders, or cashier’s checks for payment of any premium, including initial application and subsequent periodic payments. Temporary checks, Agent-written checks, and savings accounts are also unacceptable methods of payments.

8. An agent should never accept cash for payment of any premium including the initial application of subsequent premium payments.

EFFECTIVE DATES OF COVERAGE:The date an insurance policy becomes effective may be based on the date the insurance application is accepted by the Home Office or a future date requested by the Applicant. Postdating can be up to 90 days following the receipt of the application. Policies issued on monthly mode will be dated the date issued in the Home Office.

COMMISSION LOAN ADVANCEAll Commissions and Advances are handled by InSphere Insurance SolutionsSM. Please contact InSphere Insurance SolutionsSM. or your Field Leader for assistance.

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SELECTION OF RISKSThe principal function of the Underwriting Department is the appraisal and selection of health insurance risks. As a part of the risk selection process, the Underwriting Department is responsible for accepting or rejecting insurance applications, communicating the action to the appropriate parties, in addition to observing and complying with various statutes, regulations and laws that apply to solicitation, pricing and issuance of health insurance contracts. The appraisal is based on information obtained from several sources including the application, medical records, Applicant interviews, MIB and various questionnaires and other sources.

It is the responsibility of the Underwriting Department to properly evaluate all Applicants for health insurance coverage. This requires a sound modern underwriting practice consistent with the company’s general philosophy for the selection of health risks.

In order to provide the best possible service, the Home Office Underwriting Department Team must also rely on you, the Agent, to develop complete and accurate information at the point of sale.

This does not mean that just filling in the bubble or checking the box “yes” or “no” and listing a medical condition in the health section creates a complete application. There is more to it than that.

Tell us everything. There is no way to over inform the underwriter. We, as underwriters, look for applications that can create a written picture of the Applicant. No matter how insignificant that health condition may seem, if your Applicant felt it was important enough to tell you then put it on the application.

The less we know and the more we must guess about what you are trying to tell us concerning the status of a condition or the degree of recovery, the more we will investigate. This causes the application to remain pending longer, therefore delaying the Applicant’s policy and in some cases, losing the Agent’s commission.

Our Agents who can master these skills will experience the rewards of having a strong relationship with the Underwriting Department. Those who do not will continue to struggle.

Because our jobs are so interdependent upon one another and we share a common goal, we will strive to become your strongest partner. When that happens… everybody wins!

UNDERWRITING DEPARTMENT

UNDERWRITING FUNCTIONThe underwriting process may be completed with a single review of the application after completion of the Welcome Call. Additional information should be obtained from the Agent whenever possible. However, there will be certain situations where obtaining information from an outside source is desirable, such as:

1. Shaky signature, or printed signature (explain reason for shaky signature),

2. Unusually large amounts of coverage,

3. Medical condition(s) currently being treated, or a combination of several significant medical impairments,

4. Unusual tests (give us dates, reason for and results of all tests),

5. Vague conditions or illnesses (give all details for illnesses or injuries).

Home Office Underwriters request all requirements through facilities sanctioned by the Home Office.

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UNDERWRITING DEPARTMENT CONTINUED

UNDERWRITING TOOLSThis is a list of underwriting tools available for risk appraisal

1. MED-SUPP MALE FEMALE HEIGHT/WEIGHT CHART

2. Attending Physician’s Statement – is a medical report sent to us by the Proposed Insured’s attending physician. An APS will be requested only when deemed necessary. The APS and other medical records are confidential documents. If an adverse underwriting decision is made based on information from medical records, there are procedures the Applicant can follow to obtain this information: a. Upon written request from the Applicant; the

Underwriting Department will disclose the medical information in writing to the Applicant’s physician or medical facility that provided us with the medical records.

b. We can also release the information to the Applicant if we receive a written request from the policyholder along with an authorization signed by the doctor or medical facility authorizing United American to release this information to the Applicant.

3. Quality Assurance Calls (Welcome Call) – is a telephone interview process that may be used by the Underwriting Department to verify information with the Applicants or Proposed Insured to help evaluate the case. Please inform Applicants that a telephone interview may be required as a welcome call to help us determine the validity of the answers on the application.

4. MIB – Medical Information Bureau ‘s fraud protection services protect insurers, policyholders, and Applicants from attempts to conceal or omit information material to the sound and equitable underwriting of life, health, disability, and long term care insurance. See also UA’s Privacy & Disclosure Information booklet. See also MIB Group, Inc. (www.mib.com)

5. Special Questions, Medical – Specific questions on certain medical conditions that you can ask the Applicant before submitting the application which will help the underwriter in understanding the complete medical history. This will save time in processing the application because if we know all the details, we will not need to order medical records or call the Applicant or Agent to obtain the information after the application is received.

ArthritisAsthma (& Other Respiratory Disorders)Back And NeckBlood PressureCheckupDiabetesEpilepsy, SeizuresFractures, InjuriesHeart Attack, Chest PainHeart MurmurKidney, Gallbladder, UrinaryNervous Mental DisordersStomach, Intestine, Colon

6. Special Questions, Non-Medical – There are several other factors other than medical history that affect the underwriter’s decision to issue the policy. We have special questions which will help us to determine eligibility without having to go back to the Applicant or Agent for these details.

CitizenshipDrug/Alcohol Use/AbuseEmployment/OccupationAvocationReplacement of other insurance

7. Treatment – Management, consultation and care for the purpose of combating or controlling a disease or disorder. This includes any therapy, prescribed medications or over the counter medications taken to control or treat the disorder.

4’ 10” 2514’ 11” 2575’ 0” 2605’ 1” 2625’ 2” 2685’ 3” 2725’ 4” 2815’ 5” 2875’ 6” 2955’ 7” 3015’ 8” 3115’ 9” 3215’ 10” 3245’ 11” 3336’ 0” 3376’ 1” 3486’ 2” 3536’ 3” 3646’ 4” 385

HEIGHT MAXIMUM WEIGHT

FEET INCHES POUNDS

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MEDICAL SPECIAL QUESTIONSUnderwriting action on some conditions depends on severity. Following are special questions the Agent can ask regarding symptoms and treatments to help determine whether the condition is mild, moderate or severe. If we have this information with the application when it is received at the Home Office, it will help to prevent additional delays in issuing the policy.

ARTHRITIS1. Type of arthritis (i.e. Rheumatoid, Osteo,

Gouty, Degenerative, etc.)

2. What joints are involved? Swelling or Deformity?

3. What medication was prescribed? What is the current treatment?

4. What activities are restricted? How disabling is it?

5. Complete name and address of the attending physician?

ASTHMA, EMPHYSEMA, BRONCHITIS, RESPIRATORY, ALLERGIES

1. How many attacks? How severe (disabling) are the attacks?

2. Date of last attack? Hospitalized? How many days hospitalized?

3. Name of medication taken? Date of last treatment?

4. Complete name and address of attending physician?

BACK AND NECK1. What areas of the back and neck were affected?

2. How long did the symptoms last?

3. What was the date of the last symptom?

4. What treatment was recommended? For how long?

5. Current Treatment? Date of last treatment?


BLOOD PRESSURE1. Date of onset or date diagnosed with

High Blood Pressure (HBP)?

2. Is HBP controlled with medication? Currently under treatment?

3. Name of all medications used to treat HBP?


CHECKUP1. Reason for and date of checkup?

2. What symptoms prompted the checkup; or, was it a regular annual checkup?

3. Medication prescribed?

4. What tests were done and what were the results of the test?

5. Any further tests or studies recommended?


DIABETES, HYPOGLYCEMIA, GLUCOSE INTOLERANCE, OR SUGAR DISORDER

1. Date of first symptoms? Date Diagnosed?

2. Controlled by diet or medication? Name of medications and amounts taken each day? Oral medication or insulin?

3. Ever been hospitalized for diabetes? History of diabetic coma?

4. Any history of: Eye Disorders?Kidney Disorders?Heart Disorders?Recurrent Infection?Amputation?Diabetic Ulcers?

5. Any other complications of diabetes?


EPILEPSY, SEIZURE, FAINTING SPELLS1. Describe type of seizure, epilepsy or fainting spell.

2. What are the dates of the first episode and the latest episode?

3. How often do the symptoms occur? Give dates.

4. What studies have been done? Give details and results.

5. How is it treated? What medications are taken? Date and physician last seen?


FRACTURES, INJURIES, MUSCLE/TENDON SPRAIN/STRAIN, JOINT REPLACEMENT

1. Date of injury? Date of recovery? Was this a Worker’s Compensation injury?

2. Location of injury (Left or right arm, leg, knee, hip, etc.)?

3. Type of surgery?

4. Was there internal fixation (pins, plates, wire, nail, screws)? Give details.

5. Currently taking medication? Name of medication?


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HEART ATTACK, ANGINA, CORONARY ARTERY DISEASE, CHEST PAIN

1. Give dates of episodes and details.

2. If chest pains have occurred, what was the cause?

3. Type of studies done, dates and results of studies?

4. What is current treatment?

5. Are activities restricted?

6. Was a bypass operation or other surgery done or recommended?


HEART MURMUR1. When was murmur diagnosed? How was

it diagnosed? What tests were done?

2. If known, what is the type of murmur? Was it called “functional,” “innocent,” or “organic?”

3. What doctor did the tests and what doctor checked it most recently?

4. Is there any restriction of activities?


KIDNEY, BLADDER, OR OTHER URINARY TRACT DISORDERS

1. Give name of the disorder. How many episodes have occurred? Give details.

2. What tests were done and what were the results? Surgery recommended?

3. How was the disorder treated? Currently on medication?

4. If a kidney stone was present, was it passed, removed or still present? How was it removed?


NERVOUS MENTAL DISORDERS1. What was the actual diagnosis?

2. Was treatment sought from a physician, psychiatrist or other medical facility?

3. If yes, currently under treatment? Frequency of treatment? Date of last treatment?

4. Ever been hospitalized for the condition? Date of hospitalization?

5. Has there been any disability? When and for how long?

6. Was medication prescribed? Currently on medication?

7. Name and dosage of medication(s) and dates of treatment?

8. Complete name and address of attending physician or physician currently treating this condition?

STOMACH, INTESTINE OR COLON1. Was an ulcer found? What type?

2. Was it treated? For how long?

3. When was medication last taken? Name of medication?

4. Was hospitalization required or has it been advised? When and for how many days? Was there any bleeding?

5. Was any abdominal surgery performed? When and what type?

6. Currently under treatment?

7. Currently on medication? Name and dosage of medication?


THYROID1. Is Applicant hyperthyroid (overactive) or

hypothyroid (underactive)? Are nodules present?

2. How is ailment treated? If operated, was it total or subtotal thyroidectomy?

3. What symptoms did Applicant have?

4. Is condition malignant or benign?

5. What medications are taken?


TUMOR, POLYP, OR CYST1. Location of growth? If external, what part

of the body? If internal, what organ?

2. When was it removed and how?

3. Dates of treatment? Currently under treatment?

4. What was the diagnosis (malignant, benign, premalignant)?

5. What was the treatment after the growth was removed?

6. Currently on medication? Name of medication taken?


OTHER CONDITIONS NOT LISTED ABOVE1. When was the doctor seen? Give

details and reasons for visit.

2. What tests were done? Results of tests? What was the diagnosis?

3. Was medication prescribed? If yes, include the name of the medication (obtain name and dosage from the prescription bottle).

4. Currently on medication? List all medications.

5. Are there any remaining symptoms or episodes? How often? include dates.

6. Is there any residual impairment?



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NON – MEDICAL UNDERWRITING GUIDELINESGetting the policy issued goes beyond just the health of an Applicant. It extends to:

1. Obtaining all of the required signatures in all the right places on the application and forms.

2. Answering all the questions and attach all the required forms, pertaining to replacement of other coverages.

3. Attaching all of the required forms with the correct banking information for bank draft purposes.

4. Complying with state regulations and statutes set forth by our Compliance Department and Legal Department.

The underwriter will check all of these items during the initial review of the application. Your assistance in answering the following questions will help us reduce the issue time of the policy.

NONMEDICAL SPECIAL QUESTIONS

CITIZENSHIP We shouldn’t issue people without a legal standing to be in the United States. Social Security and Green cards are the normal indicators that a person has legal standing. If they don’t have a Social Security or Green card, they will be declined. With Green cards and other non-Social Security credentials, we should ask the following questions to assess the likelihood of how stable the person’s residency is in the United States. If stable, we can issue – if unstable, we will decline coverage.

QUESTIONS TO ASK REGARDING CITIZENSHIP FOR STABILITY:

1. Under what authority are you living in the United States?

2. How long have you lived in the United States?

3. Do you plan to continue living in the United States?

4. Will you be a permanent resident of the United States?

5. How frequently do you plan on traveling outside the United States?

DUI 1. Date & Type of offense?

2. More than 1 DUI? Dates of each?

3. Was driver’s license suspended? Date?

4. Has driver’s license been renewed? Date?

5. Is Applicant currently employed?


DRUG ALCOHOL USE/ABUSE 1. Type of drug/alcohol used?

2. Dates used?

3. Used only 1 time or multiple times?

4. Treatment in alcohol/drug rehab facility?

5. Dates?

EMPLOYMENTSelf employed, construction, truck driving, unemployed (Applicant with hazardous occupation is uninsurable).

1. What is the nature of your employment industry?

2. Describe your specific job duties and daily activities.

3. Where is the job site or location?

4. If truck driver, please give specific duties. Do you haul any hazardous materials? If so, give details.

5. If unemployed, give reason for unemployment.

HAZARDOUS SPORT/AVOCATION1. Describe sport or avocation.

2. How often do you participate in this sport/avocation?

Policy will be issued with an exclusion rider for injuries related to hazardous avocations.

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MEDICAL UNDERWRITING GUIDEThe underwriting actions listed in this section are general guidelines for medical risk selection. The purpose is to outline common procedures and practices usually followed when making underwriting decisions for medical risk selection. It is intended for a guide only and is not to be interpreted as a guarantee of underwriting action in ANY case. Changes to the guidelines and the underwriting actions may occur without prior notification or reprinting of this guide.

The Underwriting Department will follow these guidelines whenever appropriate, with final action being the decision of the Underwriter; however, each case must be evaluated on its own merits. There will be occasions when the underwriter will make some deviation as a matter of judgment based on additional information obtained.

Impairments not listed in this section will be given individual consideration and will be underwritten based on available medical history in accordance with generally accepted underwriting guidelines or principles.

Underwriters know that the actions they take will affect the Applicant and the Agent. They realize the decisions made on a case could cause it to be handled as a “not taken” or trigger the loss of additional cases or referrals, so these adverse decisions are never taken lightly. If business is not placed on the books no one prospers.

There will be times when it will be difficult to understand why the underwriter made the decision they did. When this happens, we will justify our reasons for decision upon the Agent’s or Applicant’s request, provided that HIPAA regulations and company policies are not violated. The APS and other records obtained from an outside source are confidential documents.

If an adverse underwriting decision is made based on information from medical records, we will require a written authorization signed by the doctor or medical facility where we obtained the records, authorizing United American to release the information to the Applicant. Or, if they prefer, the Underwriting Department will disclose information in writing to the Applicant’s physician or medical facility that provided us with the information.


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F5616

PRIVACY AND DISCLOSUREINFORMATION

UAPDI 2007

UAI0046 1207

P.O. Box 8080 • McKinney, Texas 75070-8080www.unitedamerican.com

HOME OFFICE COPY

AUTHORIZATION FOR RELEASE OF HEALTHRELATED INFORMATION

UAPDI

▲

▲▲

DET

ACH

HER

E ▲

▲

▲

THIS AUTHORIZATION IS INTENDED TO COMPLY WITH THE HIPAA PRIVACY RULE.

_________________________________________________________________ _____________________

Name of proposed insured/applicant (please print) Date of birth

_________________________________________________________________ _____________________

Name of proposed insured/spouse (please print) Date of birth

_________________________________________________________________ _____________________

Name of proposed insured/child (please print) Date of birth

_________________________________________________________________ _____________________

Name of proposed insured/child (please print) Date of birth

I authorize any health plan, physician, healthcare professional, hospital, clinic, laboratory, pharmacy, medical facility, or

other healthcare provider that has provided payment, treatment or services to me or on my behalf (“My Providers”) to

disclose my entire medical record and any other protected health information concerning me to the United American

Insurance Company (UA) and its agents, employees, and representatives. This includes information on the diagnosis

or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This also includes

information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco, but excludes

psychotherapy notes.

AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION

INSTRUCTIONS TO AGENT: THIS AUTHORIZATION MUST BE OBTAINED WITH EVERY APPLICATION

FOR INSURANCE. DETACH AND RETURN TO THE HOME OFFICE. THE APPLICANT (OR, IN THE CASE

OF A MINOR, A PARENT OR GUARDIAN OF THE APPLICANT) KEEPS THE ACCOMPANYING BOOKLET.

A. United American Insurance Company (referred to as “United American”), its reinsurers, insurance support

organizations, and their authorized representatives, may obtain medical and other information in order to evaluate

my (our) application for Life or Health Insurance.

B. Any physician, practitioner, hospital, clinic, other medical or medically related facility, the Veterans Administration,

the Medical Information Bureau, Inc., my employer and consumer reporting agency or insurance company who

possess information of care, treatment or advice of me or my children may furnish such information to United

American or its representative upon presenting this authorization or a photocopy. To facilitate rapid submission

of such information, I authorize all said sources, except MIB, to give such records or knowledge to any agency

employed by the insurance company to collect and transmit such information.

C. This authorization includes information about drugs, alcoholism or mental illness.

D. United American or its reinsurers may make a brief report regarding me or my children to other companies to whom

I have applied or may apply.

E. This authorization will be valid from the date signed for a period of two and one-half years (two years in KS, KY,

MN, NM & OK).

F. I authorize United American to obtain an investigative consumer report on me.

G. I have read this authorization and I know that I may request a copy. I acknowledge receipt of required notices.

H. ❑ I elect to be interviewed if an investigative consumer report is prepared in connection with this application.

I. ❑ I elect not to have personal information disclosed to non-affliliates of United American for marketing purposes

and to affiliates of United American for purposes other than the marketing of insurance products and service.

Administrative Offi ces: P.O. Box 8080 • McKinney, Texas • 75070-8080

A Delaware Stock Company • www.unitedamerican.com

NOTICE TO ALL APPLICANTS

Continued on reverse

John A. Smith

Jean P. Smith

Julie D. Smith

11/19/63

12/2/63

1/10/87

HOME OFFICE COPY

_________________________________________________________________ _____________________

Signature of proposed insured/applicant

Date

_________________________________________________________________ _____________________

Signature of proposed insured/spouse

Date

_________________________________________________________________ _____________________

Signature of proposed insured/child

Date

_________________________________________________________________ _____________________

Signature of proposed insured/child

Date ___________________________________ _________________________________ _________________

Writing Agent Name (please print) Writing Agent Signature

Writing Agent #

By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not

apply to this authorization and I instruct any physician, healthcare professional, hospital, clinic, medical facility, or other

healthcare provider to release and disclose my entire medical record without restriction.

This protected health information is to be disclosed under this Authorization so that UA may: 1) underwrite my

application for coverage, make eligibility, risk rating, policy issuance and enrollment determinations; 2) obtain reinsurance;

3) administer claims and determine or fulfill responsibility for coverage and provision of benefits; 4) administer coverage;

and/or 5) conduct other legally permissible activities that relate to any coverage I have or have applied for with UA.

This authorization shall remain in force for 24 months following the date of my signature below, and a copy of this

authorization is as valid as the original. I understand that I have the right to revoke this authorization in writing, at any

time, by sending a written request for revocation to UA to the attention of the Underwriting Department. I understand

that a revocation is not effective to the extent that any of My Providers have relied on this Authorization, and that, to the

extent that UA has a legal right to contest a claim under an insurance policy or to contest the policy itself, such revocation

may prevent UA from completing its review of policy claims. Such revocation shall not apply to any use or disclosure

of my protected health information specifically allowed without authorization by HIPAA and no action relating to this

authorization shall be construed as creating any restriction on the uses that HIPAA allows without my authorization. I

understand that any information that is disclosed pursuant to this authorization may be redisclosed and no longer covered

by federal rules governing privacy and confidentiality of health information.I understand that My Providers may not refuse to provide treatment or payment for healthcare services if I refuse to sign

this authorization. I further understand that if I refuse to sign this authorization to release my complete medical record,

UA may not be able to process my application, or if coverage has been issued, may not be able to process policy claims.

A recorded interview may be necessary as part of the underwriting on your application for insurance.

Telephone Number: (______) __________________ Best time to call: ❑ 8AM–Noon ❑ Noon–6PM ❑ 6PM–9PM

AUTHORIZATION FOR RELEASE OF HEALTHRELATED INFORMATION (Continued)

▲

▲

▲ D

ETACH

HERE ▲

▲

▲

I hereby acknowledge that I have received, read and understood the

enclosed information as evidenced by my signature below: PRIVACY POLICY — PG 1 DESCRIPTION OF INFORMATION PRACTICES — PG 2

NOTICE REGARDING USE OF MEDICAL INFORMATION BUREAU — PG 3

TERMINAL ILLNESS ACCELERATED BENEFIT DISCLOSURE — PG 4▲

LIFE INSURANCE BUYERS GUIDE — PG 5-7▲ HEALTH INSURANCE NOTICE OF PRIVACY PRACTICES — PG 8-10 HIPAA PRIVACY RULE - AUTHORIZATION FOR RELEASE OF

HEALTH-RELATED INFORMATION

CALIFORNIA AGENTS ONLY:Select One■ PREAPPOINTMENT NOTICE PROVIDED■ APPOINTMENT WAS NOT HELD IN HOME■ APPOINTMENT WAS NOT MADE FOR LIFE OR ANNUITY SALES

■ APPLICANT IS NOT 65+ YEARS OLD

▲ Intended for Life Insurance Applicants

UA2004

John A. SmithJean P. Smith

Apr 2, 2007Apr 2, 2007

Bill Henry

987 246-1369

United American Insurance Company takes our responsibilities and the rights of our policyholders very seriously.

The Agent must carefully review UA’s Privacy and Disclosure Information booklet (F5616).

Form UAPDI 2007 contains the following required forms:✓ UA Privacy Policy✓ Notice of Information Practices✓ Notice Regarding Use of Medical

Information Bureau✓ Terminal Illness Accelerated

Benefit Disclosure✓ Life Insurance Buyers Guide✓ Health Insurance Notice of Privacy Practices✓ HIPAA Privacy Rule – Authorization for

Release of Health Related Information

Obtain Applicant’s signature and submit the Home Office page with the application. The Applicant retains the booklet.

UA PRIVACY AND DISCLOSURE INFORMATION

13

DISCOUNT MEDICAL PLAN AND APPLICATIONIn addition to the valuable insurance coverage your clients can purchase from United American, you can help your clients save on hospital and doctor charges as well as other medical services. The following discount medical programs are available.

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POLICY CHANGE

TYPE OF CHANGE REQUIREMENTS Within 30 days

REQUIREMENTS after 30 days

UNDERWRITING REQUIRED?

PREMIUM DUE?

OKAY VIA PHONE CALL?

Add Family Members see policy provisions

Primary Insured must complete and sign current application.

Applicant must qualify based on underwriting.


Applicant must qualify based on underwriting.

yes yes no

Add Newbornsee policy provisions, date requirements vary by policy

Primary Insured must complete and sign current application


no yes

pro-rated amount

payable from date of birth

no

Add or Increase Benefits Notification from Agent or Primary Insured

Health application yes yes no

Add, Remove or Change SBR or Exclusion Riders

Notification from Agent or Primary Insured

Notification from Primary Insured

yes yes

if premium rate increases

yes

Address Change Notification from Agent or Primary Insured


no no yes

Beneficiary Change Notification from Primary Insured and change of beneficiary form

Notification from Primary Insured and change of beneficiary form

no no no

Change Effective Date Notification from Agent or Primary Insured

Proof of duplicate coverage of policy delivery slip

no re-issue dept. Will notify

yes

Change In Marital Status / Divorce



no only if adding family member

if deleting

Change Method Of Payment



no if premium is due

yes

Change Mode Of Payment



no if premium is due

yes

Conversions or Rewrites Not available within 30 days Dated application signed by Agent and Applicant

yes yes

if premium rate increases

no

Delete Family Members Notification from Agent or Primary Insured


no no yes

Delete or Decrease Benefits


Written notification from Primary Insured

no no no

DOB or Age Correction Notification from Agent or Primary Insured

Proof of age from Primary Insured

(Copy of valid Drivers License or Birth Certificate)

no yes

if premium is higher due to

age

no

Duplicate Policies Notification from Agent or Primary Insured


no no yes

Name Changelegal

Legal documents Legal documents no no no

Name Correction Notification from Agent or Primary Insured


no no yes

Reinstatementsee policy provisions

Modal payment Dated reinstatement application signed by insured

yes yes no

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REWRITES, REINSTATEMENTS, LAPSES, RESCISSIONS

REWRITESIf the new application offers the exact same overage, but it is taken within the 31 day grace period or within 31 days of the lapse date, the application will be withdrawn and the collected premium will be applied to the original policy. In this case, the Agent (if not the original Agent) will not receive any commission.

If the new application offers the exact same coverage, and is taken more than 31, but less than 90 days of the lapse date, the application will be withdrawn and the collected premium will be used to reinstate the original policy. The policy will be reinstated as of the current date and there will be an additional 10-day waiting period on pre-existing conditions.

If the new applications is received within 90 days that is similar type coverage (in the same type category, but not exact plan) and it is for a plan that we cannot convert, the application will be declined for same type coverage in force with the company.

REINSTATEMENTSAfter a health policy has been lapsed for over 90 days, with UA approval, it may be reinstated with a lapse in coverage. A reinstatement application must be completed. An additional 10 day pre-existing condition waiting period applies on health policies. The effective date of the reinstatement will be the next monthly policy date following approval. The signed reinstatement form plus the gross modal premium must be submitted.

LAPSESAny applicant who has had a life policy lapse in the last 12 months is not eligible for a new life policy.

RESCISSIONSIf, subsequent to issue, an Applicant is determined to have been ineligible for coverage at the time of the application, that policy will be rescinded and that individual will not be eligible for future coverage of any type with United American.

REFORMATIONSIf information is received that would have changed our basis of issue due to unadmitted health history, the policyholder will be given the option of having the policy reformed to the way it would have been issued had we known the information, or have the policy rescinded and not be eligible for additional coverage with the company.

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gent MAnuAl & underwriting guidelines

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